Expanding Facial Hematoma: Recognition and Initial Management

Almost every injector has seen a bleeding point turn into a purple patch. What separates the harmless scare from the serious problem is behavior: ecchymosis stains and stops, an expanding hematoma grows. When a collection of blood expands in a limited space, pressure rises and begins to threaten tissue, blood supply and, in certain areas, vision or breathing.

This guide helps recognize an expanding hematoma, tell it apart from similar presentations and organize the initial management. It is not a surgical protocol and does not replace emergency services. Prevention and preparation are covered in anti-inflammatories and bruising in HOF, anticoagulants and injectable procedures and hypertension and bruising risk.

How to tell ecchymosis, hematoma and expanding hematoma apart?

Ecchymosis and hematoma are common and usually benign. The cutoff is progression: an increase the eye can detect between one assessment and the next is the sign that changes management.

Why does the hematoma grow?

The most common cause is injury to a vessel during injection, which keeps bleeding until hemostasis is achieved. Some factors favor it:

• larger vessels or those with a variable course, such as branches of the facial artery and of the orbital plexus;
• use of anticoagulants, antiplatelet agents, anti-inflammatories and supplements that alter coagulation, see supplements and bruising risk;
• uncontrolled hypertension;
• coagulation disorders, see coagulation disorders in HOF;
• areas with loose tissue and room to accumulate, such as the eyelid and neck;
• injection into deep planes or with larger-gauge instruments.

Which signs indicate severity?

Severity depends on the area and on how fast it grows. Some signs deserve immediate action:

1. Periorbital region: eye pain, an eye that looks bulging, difficulty moving the eye, blurred, double or lost vision, a tense eyelid. It may indicate increased pressure in the orbit.
2. Neck and submandibular region: growing swelling, difficulty swallowing or breathing, altered voice, a feeling of tightness.
3. Skin over the hematoma: pallor, darkening, disproportionate pain and extreme tension, suggesting compromised perfusion.
4. A hematoma that keeps growing despite adequate pressure.
5. Systemic signs: dizziness, falling blood pressure, generalized pallor, which suggest significant blood loss.

What is the initial management in the office?

First-line management is simple and starts the instant blood appears.

The details of timing and maneuvers depend on experience and on the facility. The guiding principle is that early, well-applied pressure resolves most cases. For preparing the practice, see emergency kit for the HOF practice and complication SOP.

What not to do?

• Release the pressure to look every few seconds, which restarts the bleeding.
• Apply heat, which increases flow.
• Try to drain without preparation, in an office without the setup.
• Discharge the patient without observing stability, especially in a risk area.
• Downplay a complaint of pain or vision changes, attributing it to anxiety.
• Delay referral out of fear of owning the complication.

What if there is doubt between hematoma and vascular occlusion?

The two presentations can coexist and be confused. An expanding hematoma can compress vessels and cause ischemia; an occlusion can come with swelling and color change. What helps:

When in doubt, treat the more serious possibility and do not delay help. Management of occlusion is in vascular occlusion vs anesthesia blanching and in the area-specific pages.

How to advise the patient afterward?

Once controlled, the hematoma is still a problem for the patient, who is left with a visible bruise and questions.

Explain that the bruise can travel down the face with gravity and last from a few days to weeks. Residual hyperpigmentation, when it occurs, follows a different line of reasoning; see residual pigmentation after ecchymosis and infraorbital hyperpigmentation after a procedure.

What to record and report?

Document the time, area, instrument, product and lot number, management and progress, with photos. Inform the patient in writing, with the warning signs. If the event involved a product, consider reporting it through the surveillance pathway, as in adverse event reporting in Notivisa (Brazil's health surveillance system), and document it according to recording the complication in the patient record.

And in Harmy?

Summary

An expanding hematoma is recognized by growth, not by color. Firm, immediate pressure, serial reassessment, special attention to the orbit and neck, and a willingness to refer early determine the outcome. When there is a visual or breathing complaint, call emergency services without delay and document everything.